U chapter 25 vital signs by chapter

While recording the pulse of an infant at 160 beats/min, the parent asks if it is normal for the infant's pulse rate to be so high. Which statement by the nurse best answers the parent's question? "Every infant's heart rate is different, so you will need to discuss that with the health care provider." "A heart rate of 160 beats/min is normal for a healthy infant." "A heart rate of 160 beats/min is actually slow for an infant, so I will ask the health care provider to reassess." "A heart rate of 160 beats/min is a little too fast for an infant, so I will take it again in 5 minutes."

"A heart rate of 160 beats/min is normal for a healthy infant."

A client admitted with dehydration reports feeling dizzy with ambulation. What teaching would the nurse provide to the client? "Dizziness is caused by very low blood pressure when you lie down." "Dizziness when you change position can occur when fluid volume in the body is decreased." "Dizziness can occur when baroreceptors overreact to the changes in BP." "Dizziness can occur due to changes in the hospital environment."

"Dizziness when you change position can occur when fluid volume in the body is decreased."

The nurse is teaching an adult client how to monitor the pulse rate. Which statement by the client demonstrates understanding of a normal pulse rate? "It is normal for my pulse to be lower than 40 beats/min while sleeping." "The normal pulse rate is 12 to 20 beats/min." "If my pulse is higher than 100 beats/min at rest, that is considered abnormal." "I will call the health care provider if my pulse is below 80 beats/min."

"If my pulse is higher than 100 beats/min at rest, that is considered abnormal."

When assessing an infant's axillary temperature, it will be: the same as the tympanic temperature. 1°F (0.5°C) lower than an oral temperature. 1°F (0.5°C) higher than an oral temperature. 1°F (0.5°C) higher than a rectal temperature.

1°F (0.5°C) lower than an oral temperature.

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure? 224 mmHg 112 mmHg 40 mmHg 132 mmHg

40 mmHg

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? Assess the apical pulse. Document the findings. Assess the carotid pulse. Get another nurse for validation.

Assess the apical pulse.

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? Document the findings. Assess the carotid pulse. Assess the apical pulse. Get another nurse for validation.

Assess the apical pulse.

The nurse is caring for a client who has had a left-sided mastectomy. Which action will the nurse take? Keep the left hand raised above the heart while assessing the blood pressure. Assess the blood pressure in the left wrist. Assess the blood pressure in the right arm. Position the right arm below heart level.

Assess the blood pressure in the right arm.

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next? Compare with previously documented findings Auscultate the apical pulse for 60 seconds Obtain a bedside electrocardiogram Report the findings to the health care provider

Auscultate the apical pulse for 60 seconds

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? Auscultate the client's apical heart rate. Palpate the radial pulse on the opposite wrist. Reassess the client's radial pulse in 15 minutes. Page the client's primary care provider.

Auscultate the client's apical heart rate.

A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? Perform a pain assessment. Administer oxygen. Notify the health care provider. Auscultate the lung sounds and count respirations.

Auscultate the lung sounds and count respirations.

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger? Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomatic. Client stands at bedside, becomes pale, diaphoretic. After 3 minutes of sitting, BP 100/50; HR 90.

Client stands at bedside, becomes pale, diaphoretic.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature? Increase the client's metabolic rate. Set up a fan to blow warm air on the client. Give the client a bath in tepid water. Apply a blanket on the client.

Give the client a bath in tepid water.

The nurse instructs a parent of young children how to properly use a nonmercury glass thermometer. Which statement made by the parent indicates a need for further instruction? "I will clean the thermometer in the dishwasher." "I will wait 30 minutes before taking an oral temperature if my child ate or drank." "The thermometer is placed under the tongue with mouth and lips closed." "I will store the thermometer in the case that it came with."

I will clean the thermometer in the dishwasher."

A nursing student is manually taking the client's blood pressure. Which step will demonstrate the correct way of inflating the blood pressure cuff? Elevate arm above heart level before inflating the cuff. Place cuff 8 cm above the elbow. Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared. Fully inflate cuff for about 1 minute.

Inflate the cuff to 30 mm Hg above reading where brachial pulse disappeared.

The nurse is preparing to assess a rectal temperature on an adult client. What is the appropriate nursing intervention? Provide privacy for the client. Maintain probe position in rectum for 2 minutes. Position the client on the stomach. Insert the thermometer 0.5 in (1.25 cm) into the rectum.

Provide privacy for the client.

The nurse is obtaining and recording vital signs of an adult client in the emergency department. Which finding should be reported to the health care provider? Temperature 99.1°F (37.3°C) Respirations 15 breaths/min Blood pressure 110/50 mm Hg Pulse 51 beats/min

Pulse 51 beats/min

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? Call for assistance and anticipate the need for CPR. Leave the thermometer in and notify the physician. Remove the thermometer and assess the temperature via another method. Remove the thermometer and assess the blood pressure and heart rate.

Remove the thermometer and assess the blood pressure and heart rate.

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next? Wait 20 minutes and recheck oral temperature. Recheck BP level to ensure accuracy Take pulse again to assess for tachycardia Talk with client to allow them to relax before retaking vital signs.

Take pulse again to assess for tachycardia

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate? This infant will need a home cardiac monitor set up. The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. The parents will not be able to check the pulse accurately; the nurse will need to do home health checks on this infant on a periodic basis. The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse.

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse.

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse? The radial pulse is difficult to obtain. A baseline pulse rate is needed. The carotid pulse is bounding. The blood pressure is elevated.

The radial pulse is difficult to obtain.

Which client's blood pressure best describes the condition called hypotension? The systolic reading is above 102 and diastolic reading is above 60. The systolic reading is above 110 and diastolic reading is above 80. The systolic reading is below 120 and the diastolic reading is below 80. The systolic reading is below 100 and diastolic reading is below 60.

The systolic reading is below 100 and diastolic reading is below 60

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. To take the medication that she missed and retake her BP Not to worry and to take double the dose of BP medication To call her health care provider

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

The student nurse is having difficulty feeling the pedal pulse of the client with a fractured leg. What should the nurse do next? Use the Bell side of the stethoscope to listen. Use the Doppler ultrasound device. Connect the client to the oxygen saturation monitoring device. Ask another student nurse to check it for him.

Use the Doppler ultrasound device.

An ultrasonic Doppler is used for: auscultating a pulse that is difficult to palpate. auscultating diastolic blood pressure. aiding palpation of diastolic blood pressure. aiding palpation of pulse and rhythm.

auscultating a pulse that is difficult to palpate.

Which factor is not known to cause false blood pressure readings? crossing the legs at the knee being in a warm environment smoking 20 minutes before assessment eating 5 minutes before assessment

being in a warm environment

The body loses heat continually through several different processes. Which process is an example of how heat is lost through evaporation? diaphoresis convection conduction radiation

diaphoresis

The nurse is caring for a client who has smoked for more than 20 years and is now experiencing labored respirations. The nurse documents the client is experiencing: fremitus. wheezing. stridor. dyspnea.

dyspnea.

The nurse knows that a client who is being taught to perform home blood pressure monitoring (HBPM) understands the teaching plan when he makes which statement about the size of the BP cuff? The cuff should: fit snug around the upper arm with room to slip three fingertips under the cuff and should be 1 in (2.5 cm) above the crease of the elbow. fit snug around the upper arm with no room to slip a fingertip under the cuff and should be 2 in (5 cm) above the crease of the elbow. fit snug around the upper arm with room to slip a fingertip under the cuff and should be touching the crease of the elbow. fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

fit snug around the upper arm with room to slip a fingertip under the cuff and should be 1 in (2.5 cm) above the crease of the elbow.

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with: decreased heart rate. decreased respirations. increased temperature. increased cardiac output.

increased temperature.

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? listen with a stethoscope at the second intercostal space left sternum listen with a stethoscope at the neck to the right of the coracoid process listen with the stethoscope at the fifth intercostal space at the sternum listen with the stethoscope at the fifth intercostal space left mid-clavicular line

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as: tachypnea apnea orthopnea bradypnea

orthopnea

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? light palpation of the femoral pulse below the inguinal area firm palpation of bilateral carotid artery for one minute firm placement of thumb on the inner wrist of the opposite arm palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

palpation of the radial pulse on the thumb side of the inner aspect of the wrist.

A nursing student is assessing blood pressure in an adult client. Which action by the nursing student would require intervention from the nursing instructor? placing the ear tips of the stethoscope forward into the ear using light pressure over the anatomic site for assessment placing the client's arm in a comfortable resting position pumping the blood pressure cuff up to 200 mm Hg routinely

pumping the blood pressure cuff up to 200 mm Hg routinely

Which term indicates a potentially serious client condition? pulse pressure afebrile pyrexia eupnea

pyrexia

A nurse is caring for an adult with fever. The nurse determines that which site is most accurate for obtaining the client's core body temperature? rectum mouth ear axilla

rectum

The nurse is preparing discharge teaching for a client admitted for sepsis. The client asks what is included when the nurse checks vital signs. Which assessment(s) is included? Select all that apply. pulse allergies temperature respiratory rate blood pressure weight

temperature pulse respiratory rate blood pressure

A pulse deficit is the difference between: the radial pulse and the ulnar pulse rates. palpated and auscultated blood pressure readings. the systolic and diastolic blood pressure readings. the apical and the radial pulse rates.

the apical and the radial pulse rates.